2. Matters Patient Safety Matters Matters 2006 San Antonio 2005 11th European Forum 2006. Prague. WONCA AHRQ Resource Center How Does The Patient Safety Research Center See and deal with these matters and why are others, such as, Interested in our work ?

3. Our Vision International Champion of Patient safety SAR-AIMER Systematic Appraisal of Risk And Its Management for Error Reduction

4. We are about Placing Patient Safety at the of Medical Education andPractice

5. CONTENT OF THIS AND THE OTHER THREE PRESENTATIONS CONTENT OF THIS AND THE OTHER THREE PRESENTATIONS Our Mission, Driving principles, Premises, and Implications The Burden of Lack of Safety on the Nation The Opportunity Our approach to lightening the Burden Main Areas of our Activity Education/training Safety Practice Enhancement Covered in the other three presentations

6. Pursuit of excellence in patient safety in the various domains of healthcare by applying systems-safety science, systems-engineering principles and systems-management strategies for building adaptive learning practices with self-empowered teams providing care with highest professionalism and integrity Mission

7. Driving Principles Driving Principles Holism This is the inspiration behind Systems Approach and complexity science Natures way of creating wholes that are more than the sum of the parts Aristotle through creative evolution Singh 1987 Cybernetics Science of observed systems + Science of observing systems Art Of 1940 Goals Predictions Actions Feedback Response Supremacy of Relevance over Rigor Reductionism gives rigorous answers, but to wrong questions Better an approximate answer to a right question Singh 1987 Aristotle 300.. BC & GS 1976 Not succumbing to the prevailing “Hegemony” and “Greedy Reductionism” So that we can broaden the view of EBM Berwick

8. Patient Safety Is “freedom from accidental injury due to medical care or medical error” (US IOM) UN: WHO is working towards declaring it a Basic HUMAN RIGHT There is already a “London Declaration” by WHO Singh: April 2005

9. Safety is a fundamental system property. Without safety there can be no quality of care IOM Patient Safety Is “freedom from accidental injury due to medical care or medical error” © Gurdev Singh 2007

10. The Burden Singh: April 2005

12. This constitutes nearly 50% of the surgical “Never Events” Wrong body part : 30% Wrong procedure : 16% Wrong patient: 4% CMS press release 2006 (Minnesota Study) Foreign ‘Body’

13. And then there are other adverse Events!! US Healthcare Geriatrics carry the maximum share of this burden In 2001 there were 4.3 million ambulatory visits for treating Adverse Drug Events Zhan et al 2005 There is little or no understanding of the incidence rates, costs and prevention strategies of medication errors IOM 2006 7.75 million office visits by the elderly resulted in the prescribing of at least one medication from the list of 20 drugs judged potentially inappropriate in the elderly Aparasu 1997 One of the costlier outcomes of drug related morbidity is hospitalization. Gurwitz 1995 59% are preventable Cooper 1996 Morbidity and mortality as a result of drug-related problems in the ambulatory settings may cost more than $177 Billion/yr Cooper 1996 The (US) National Burden of Systemic Errors in the Health Care More than ‘n’ Jumbo jets of the Health Care Industry drop out of the sky every day ! (Analogy after Leape: the Safety Guru of USA) In ambulatory care of just Medicare patients- over half a million preventable ADE’s due to errors of commission alone Gurwitz et.al 2003 © Gurdev Singh 2007 1.5 Million/year Incidents of Harm IHI/IOM 1.7 million infections per year in US hospitals i.e. 4.5 infections for every 100 admissions 1.5 million medication errors occur in hospitals each year. One in five elderly patients is given medicines that may not be good for them Clancy 2007

14. AUSCANGERNZUK USA Overall Ranking 4 5 1 2 3 6 Patient Safety 4 5 2 3 1 6 Effectiveness 4 2 3 6 5 1 Patient-centeredness 3 5 1 2 4 6 Timeliness 4 6 1 2 5 3 Efficiency 4 5 1 2 3 6 Equity 2 4 5 3 1 6 Health Expend./Capita $2903 3003299618862231 $5,635 International Rankings and National Health Expenditure (Through Patient’s Lens) Source: The Commonwealth Fund : 2006. $7600 ?

15. Jan. 2008 Commonwealth Fund reveals interesting picture of effectiveness

16. “Amenable mortality - deaths from certain causes before age 75 that are potentially preventable with timely and effective health care”

17. © Gurdev Singh 2007 1.000,000 100,000 10,000 1000 100 10 1 Adverse Events Per Million Opportunities 6 3 1245 S I G M A aviation IOM MEDICATION Healthcare Safety Comparison with Civil Aviation σσ Adapted from Robert Galvin ( GE, MOTOROLA ) © Gurdev Singh 2003-7 Not a fair but a telling comparison

18. 100,000 10,000 100 10 1 Lives Lost per year 10 Encounters (opportunities) for Each Fatality Hazard Comparisons (rough) (AHRQ) After AHRQ A R G Singh: 2004/7 1001,00010,000100,0001,000,000 10,000,000 Bungee Jumping Health Care Dangerous More than 1 in a thousand Very Safe Less than 1 in 1000 thousand Chartered Flights Scheduled Flights 1000 Driving Nuclear Power

19. Split of $2.3 trillion US National Budget of a fragmented and decentralized HC System R and G Singh Cost of Hospitalization 31% 30 - 40 % is the Cost of Admin. Wastage 30-40% Includes costs of other settings and Costs of harm to patients !

20. Payers of $2.3 trillion US HC Costs Public Funds: Medicare Medicaid Other 45% Consumer Out of pocket Private 19% Employer- Provided Insurance 36% Please see this in the context of the fact that every 30 seconds an American is driven to bankruptcy due to health care costs

21. A, R & G Singh: Jan. 2005 The chasm between what is done and what can be done is about 50% © Gurdev Singh 2007 30 - 40% of the huge Health Budget is wasted 35% of $2.3 trillion HB >> $700 Billion/yr!

22. Congressional Budget Office Head, Peter Orszag: Times Nov 08 If this is not a MAJOR National Disaster our name is not Singh !

23. The total cost of medical injury in the health care system is estimated to be $200 billion per year which is about one fifth of the national health budget. (AARP 1998 Research Report) Singh: April 2005

24. Take Home: We must create and ride a health machine that will “change the world” We want a “Toyota of Health Care” R & G Singh: Aug. 2002 We can all play a role in making this a reality Or live with outsourcing : “Health tourism” and “Health refugees”

25. >0.5 million/year are outsourced. These numbers are on a ‘steep climb’ AARP Sep.2007

27. Importance of Patient Safety Formidable and Compelling Pressures: Federal Government Institute of Medicine (IOM) Professional Bodies Accreditation Authorities If we do not heed they will make errors “expensive for us” A R G Singh: 2002/7

28. Importance of Patient Safety In year 2000 Inst. Of Medicine was seeking 50% reduction in errors by 2005 !!!!!! Progress so far has been only modest and highly variable! A R G Singh: 2003/7

29. Medicare says it won’t cover hospital errors “Never Events” Aug 2007 A R G Singh: 2003/7

30. FOR About 2 trillion Patient Safety Improvements are Likely to provide the biggest